1. An Holistic Approach
Updated 12/9/2009 1

2. Palliative Care
 Learning Outcomes for this work shop:
 1. Demonstrate knowledge of the principles and
philosophies of a palliative approach in the Aged Care
setting.
 2. Improve the knowledge of the roles of the palliative
care team.
 3. Understand pain & symptom management principles.
 4. Demonstrate an understanding of the psychological &
spiritual support mechanisms.
 5. Know where to seek more advice.
Updated 12/9/2009 2

3. Palliative Care
 Standard 2.9 – Palliative Care
 Expected outcome – the comfort & dignity of
terminally ill residents is maintained.
 Criteria – Policies & Practices provide:
 A. that residents wishes are identified, respected and where
possible, acted upon in relation to their terminal care; and
 B. individual palliative care programs that enable family
involvement, accommodate religious and cultural beliefs and
recognise an individual’s right to die with dignity.
Updated 12/9/2009 3

4. Palliative Care
 Definition :
 WHO –
 Palliative care is an approach that improves the quality
of life of patients and their families facing the problems
associated with life threatening illness, through the
prevention and relief of suffering by means of early
identification , assessment & treatment of pain and
other problems, physical, psychosocial and spiritual.
Updated 12/9/2009 4

5. Palliative Care
 Palliative care :
 Provides relief from pain and other distressing
symptoms,
 Affirms life & regards dying as a normal process,
 Intends neither to hasten or postpone death,
 Integrates the psychological & spiritual aspects of
patient care,
 Offers a support system to help patients live as actively
as possible until death,
Updated 12/9/2009 5

6. Palliative Care
 Offers a support system to help the family cope during
the patient’s illness and in their own bereavement,
 Uses a team approach to address the needs of the patient
and their family, including bereavement counseling,
 Will enhance the quality of life and may also positively
influence the course of the illness.
 (WHO – definition of palliative care –
www.who.int/cancer/palliative/definition/en/)
Updated 12/9/2009 6

7. Updated 12/9/2009 7

8. Palliative Care
 The need for palliative care does NOT depend on
diagnosis, but on the individual person’s needs –
particularly the complexity & severity of a person’s
distress or their potential for distress.
Updated 12/9/2009 8

9. Palliative Care
 The primary goal of palliative care in an
aged care setting is to :
 Improve the resident’s level of
comfort & function,
 And to address their
psychological, spiritual & social
requirements.
Updated 12/9/2009 9

10. Palliative Care
These categories underpin
the provision of care, and
therefore the guidelines to
assist practice through an
educative process.
The guidelines are inter-
related and no one should
be considered in isolation
from the others
Updated 12/9/2009 10

11. Updated 12/9/2009 11

12. Palliative Care
 A palliative approach aims to improve the
quality of life for individuals with a life-limiting
illness and their families, by reducing their
suffering through early identification, assessment
and treatment of
pain, physical, cultural, psychological, social, and
spiritual needs.
Updated 12/9/2009 12

13. Updated 12/9/2009 13

14. Palliative Care
 Underlying the philosophy of a palliative approach
is a positive and open attitude towards death and
dying.
 The promotion of a more open approach to
discussions of death and dying between the aged
care team, residents and their families facilitates
identification of their wishes regarding end-of-life
care.
Updated 12/9/2009 14

15. Palliative Care
• A palliative approach is not confined to the end
stages of an illness.
• A palliative approach provides a focus on active
comfort care and a positive approach to reducing
an individual’s symptoms and distress.
• This facilitates residents’ and their families’
understanding that they are being actively
supported through this process.
Updated 12/9/2009 15

16. Palliative Care
 What are the barriers to a Palliative Approach?
 1. In Western society people are often afraid of
discussing death & dying.
 2. There is confusion between palliative care and
euthanasia.
 3. ACF’s often do not have up to date knowledge and
definitive guidelines about Palliative Care and when and
how to implement it.
 4. Specialist knowledge (ie. A Palliative Care team) is
often not sought.
Updated 12/9/2009 16

17. Palliative Care
 An Australian study has projected that there will be a
70% increase in older Australians over the next 30
years with profound disabilities.
 Conditions included are :
 Neurological – Parkinson’s, stroke, dementia, motor neurone disease.
 Musculoskeletal – arthritis, osteoporosis, muscular dystrophy,
 Circulatory – vascular disease, heart attack, heart failure.
 Respiratory – COPD, asthma, emphysema, cystic fibrosis.
 Endocrine – diabetes.
 HIV/AIDS
 Cancer
 Renal & liver disease.
Updated 12/9/2009 17

18. Updated 12/9/2009 18

19. Palliative Care
 Advance Care Planning :
 The Aged Care Act stipulates that residents must be
given the opportunity to make choices about their care.
 This includes their right to agree or refuse treatments
offered.
 Advanced Care Planning is a process which enables the
resident to be able to make decisions about their end-of-
life wishes in writing, which then removes the burden
of responsibility from the surrogate and leaves the
control with the resident.
Updated 12/9/2009 19

20. Palliative Care
 If the resident is unable to make these
decisions, It’s important for families to
be involved in all steps of the planning
process, including acceptance or
refusal of treatments and ongoing care.
Updated 12/9/2009 20

21. Palliative Care
 Having “The Discussion” regarding end-of-life
wishes.
 Best done either before admission to the ACF, or
immediately upon arrival.
 If not done, treatment decisions will be made on the run
in crisis mode, and unnecessary transfers to hospital or
unwanted treatments which do not meet the goals or
wishes of the resident or family may occur.
Updated 12/9/2009 21

22. Updated 12/9/2009 22

23.  Advance Directive documents tend to address issues
such as pain control, comfort care, place of dying and
hospital admission.
 These documents need to be flexible to take into
account unforeseen incidents, such as fractured hip or
pneumonia.
 No one should be forced to participate in the discussion
if not willing.
Updated 12/9/2009 23

24. Palliative Care.
 See document – “Clinical Practice Guidelines for
communicating prognosis and end-of-life issues with
adults in the advanced stages of a life-limiting
illness, and their caregivers.”
 www.mja.com.au
 MJA supplement, 18 June 2007, Volume 186, number
12.
Updated 12/9/2009 24

25. Palliative Care
 Identifying the three forms of Palliative care -
 1. The Palliative Approach
 2. Specialised palliative service provision
 3. End-of-life care.
Updated 12/9/2009 25

26. Palliative Care
 1. The Palliative Approach –
 Appropriate when the resident’s condition cannot be
cured, and the symptoms require intervention.
 The goals are to:
 Improve the resident’s level of comfort &
function,
 And to address their psychological, spiritual &
social requirements.
Updated 12/9/2009 26

27. Palliative Care
 2. Specialised palliative service provision
 – appropriate when the resident requires specific &
focused input by a specialist team – eg. Eastern Palliative
Care. Not meant to replace the palliative approach, but
runs in conjunction with it.
Updated 12/9/2009 27

28. Palliative Care
 The goals are to assess and treat complex symptoms
being experienced by the resident and providing the
information to the aged care team on complex issues like
family issues, ethical dilemmas, distress.
 Should be managed in a timely manner, and not in
response to crisis.
 May require transfer to hospice for expert palliation if
facility is not able to manage.
Updated 12/9/2009 28

29. Palliative Care
 3. End-of-life care – implemented in the final days or
weeks of life.
 Care decisions may need to be reviewed on a frequent
basis – daily or more often.
 The goals are focused towards the resident’s
physical, emotional & spiritual comfort, and supporting
the family.
 Can be a difficult time to identify as residents often have
multiple co-morbidities and have a gradual slide in their
condition.
Updated 12/9/2009 29

30. Palliative care
 Symptoms that may indicate the end-of-life phase :
 Requiring more frequent intervention – pain
management, positioning, etc.
 Loss of appetite (anorexia)
 Profound weakness
 Trouble swallowing (dysphagia)
 Dry mouth
 Weight loss
 Lapsing in and out of consciousness
 Day to day deterioration.
Updated 12/9/2009 30

31. Palliative Care
 It is important to :
 Respect the choices that the resident & family members
make with regard to treatment options,
 Be available to discuss issues with residents and family
members,
 Provide information in a pro-active way – organise
family & doctor meetings when the resident’s condition
changes, to keep them informed every step of the way.
 Allow the family to prepare for the imminent death of
their loved one by keeping them informed of changes as
they occur.
Updated 12/9/2009 31

32. Palliative Care
 Who is involved in the Palliative (multidisciplinary)
Care Team?
Updated 12/9/2009 32

33. Updated 12/9/2009 33

34.  1. Personal care assistants
 2. GP’s
 3. RN’s
 4. Palliative Care nurses
 5. Volunteers
 6. Chaplains or pastoral care workers
 7. Pharmacists
 8. Pain specialists
 9. Activities co-coordinators, music therapists, social
works, aromatherapists
 10. Pharmacists
 11. Specialist – oncologist, radiotherapists, surgeon
 12. Psychologist, grief counselor.
Updated 12/9/2009 34

35. Updated 12/9/2009 35

36. Updated 12/9/2009 36

37. Palliative Care
Palliative Care is a TEAM effort.
Updated 12/9/2009 37

38. Palliative Care
 It is critical that one member of the team assumes the
coordinator’s role – eg. RN, GP or DON.
 Teamwork between the RN & GP is essential.
 The team must be able to meet regularly and assess
and discuss management and progress.
 The team should be non-heirarchical.
 The staffing skill mix should be determined on the
individual needs of the family members and resident.
 It is recommended that at least one member of the
team has formal training in the palliative approach.
Updated 12/9/2009 38

39. Palliative Care
 Pain & Symptom Management
 Pain – “pain is a subjective sensation… and is what the patient says it
is, and not what others think it should be…”
 1. physical suffering or distress, as due to
injury, illness, etc. 2. a distressing sensation in a
particular part of the body: a back pain. 3. mental or
emotional suffering or torment: I am sorry my news
causes you such pain.
 www.dictionary.com
Updated 12/9/2009 39

40. Updated 12/9/2009 40

41. Palliative Care
 Other symptoms :
 Loss of appetite (anorexia)
 Nausea
 Profound weakness / fatigue
 Trouble swallowing (dysphagia)
 Dry mouth
 Weight loss
 Lapsing in and out of consciousness
 Day to day deterioration.
 Insomnia
 Bowel problems – diarrhoea / constipation
Updated 12/9/2009 41

42. Palliative Care
 Pain Management
 Often under treated in many ACF’s and hospitals.
 Often misunderstood.
 Treated on fixed regimes that are not flexible or
responsive to the need of the resident, eg. 4/24
analgesia.
Updated 12/9/2009 42

43. Palliative Care
 Often treated only in the physical element, not
including spiritual, social & psychological elements.
 In an Australian study it was found that 22% of residents
who stated they had no pain had no record of
medication administration recorded in their case
notes, and 16% did not have analgesia ordered at all!
Updated 12/9/2009 43

44. Palliative Care
 Barriers to pain management :
 Lack of knowledge among nurses and GP’s
 Lack of observation skills for pain indicators among
PCA’s, and inadequate reporting.
 Fear of the consequences of reporting pain among
residents – reluctant to complain.
 Residents become resigned to their pain.
 Generational “stoic” ideals – ‘stiff upper lip’.
 Cultural misconceptions.
Updated 12/9/2009 44

45. Updated 12/9/2009 45

46. Palliative Care
 Review ‘Fast Fact #008 – Morphine & Hastened Death’.
 What are the differences between euthanasia &
palliation?
Updated 12/9/2009 46

47. Palliative Care
 Morphine toxicity will cause drowsiness, confusion and
loss of consciousness before the respiratory drive is
compromised.
 If the intent of the therapy is to help the patient and
have a potentially good outcome – eg. Relief of pain - but
there is a potentially adverse secondary
consequence, the treatment is considered ethical.
 Euthanasia is not an example of double effect – the
intent is to end the patient’s life.
Updated 12/9/2009 47

48. Palliative Care
 If the intent of giving morphine is to relieve
pain, and accepted dosing guidelines are
adhered to, then :
 The treatment is considered ethical
 The risk of a potentially adverse secondary
effect is minimal, and
 The risk of respiratory depression is vastly
over-estimated.
Updated 12/9/2009 48

49. Palliative Care
 Tools for assessing pain :
 1. Pain assessment – should state pain
location, type, frequency & severity, as well as the
impact this pain has on the ADL’s.
 2. Abbey Pain scale for patients unable to verbalise pain.
Updated 12/9/2009 49

50. Updated 12/9/2009 50

51. Palliative Care
Deciding how and when to implement analgesia.
Updated 12/9/2009 51

52. Palliative Care
 Opioids used conventionally for moderate pain
 - codeine, hydrocodone, oxycodone.
 Typically combined with non-opioid (e.g. Tylenol)
which limits dose titration
 Opioids used conventionally for severe pain
-
morphine, fentanyl, oxycodone, methadone, oxymorp
hone
Updated 12/9/2009 52

53. Palliative Care
Tolerance to analgesia:
 A change in the dose-response relationship induced by
exposure to the drug and manifest as a need for higher dose
to maintain an effect.
 Develops at different rates to these varying effects
 - respiratory depression, nausea, constipation
 Analgesic tolerance is rarely a problem
 - opioid doses remain relatively stable in the absence of
worsening pathology and increased opioid requirements
after stable periods is often a signal of disease progression
Updated 12/9/2009 53

54. Palliative Care
 Principles of Pain Management :
 Mild pain - Regular (4/24, 6/24 or 8/24) use of
Paracetamol or NSAID’s.
Updated 12/9/2009 54

55. Palliative Care
 Moderate Pain – regular weak opioids – codeine or
tramadol +/- adjuvant therapy steroids, NSAID’s
(used with caution), tricyclic
antidepressants, anticonvulsants.
Updated 12/9/2009 55

56. Palliative Care
 Severe Pain – paracetamol + opioids patches –
fentanyl (Durogesic) or buprenorphine
(Norspan), morphine – oral, IM or S/C – by butterfly or
syringe driver.
Updated 12/9/2009 56

57. Palliative Care
 Management of side effects of pain management :
 Constipation – regular aperients, increased as the
opioids increase.
 Nausea & vomiting – usually occurs initially, then
settles. Controlled with Maxalon, sometimes
stemetil, and Zofran. Also can be controlled with
phenergan.
 Dry mouth – regular mouth care, ice chips, regular sips.
 Confusion or hypersomnolence (tend to cause sleep) –
refer to GP or specialist for review.
Updated 12/9/2009 57

58. Palliative Care
 Fatigue – NEVER normal – always a symptom of
something!
 Causes – anorexia/cachexia (wasting emaciation)
- boredom
- pain
- psychological issues – depression & anxiety.
- sleep disturbance
- medications
- dehydration
- nausea / vomiting
* Treating the cause can help to alleviate fatigue.
Updated 12/9/2009 58

59. Palliative Care
 Cachexia – a syndrome combining weight loss, loss of
muscle and visceral protein, anorexia, chronic nausea
and weakness.
 Common in cases of cancer, but also chronic heart
failure, renal failure and dementia.
 More often a cause of distress to the family, and may
cause extra anxiety about their loved one’s condition.
 Family requires extra education about not force feeding
their loved one at this time.
 Can be managed with protein drinks and supplements if
patient allows it.
Updated 12/9/2009 59

60. Palliative Care
 Nausea & Vomiting:
 Causes in palliative care –
 1. decreased gastric motility or gastroparesis – from decreased
mobility, medications or decreased neuromuscular control)
 2. constipation – treat with aperients
 3. medications – opioids – treat with anti emetics
 4. hyperacidity – treat with antacids
 5. dehydration – treat with fluids or sips
 6. unpleasant odours or cooking smells – remove the source.
 TREAT THE CAUSE TO HELP ALLEVIATE SYMPTOMS.
Updated 12/9/2009 60

61. Palliative Care
 Personal Care –
 The personal carer can do so much to ensure that the
final stages of life are as comfortable as possible. Some
of the areas to be managed are :
 Personal hygiene
 Mobility & positioning
 Breathing difficulties
 Nutrition & hydration
 Elimination
 Skin care
 Spiritual needs
Updated 12/9/2009 61

62. Updated 12/9/2009 62

63. Palliative Care
 Personal hygiene –
 Ensure adequate analgesia has been given prior to
hygiene.
 Ensure room is warm and comfortable.
 Have everything prepared before commencing.
 May want to use aromatherapy – under the guidance of a
trained aromatherapist, and resident or family
permission.
Updated 12/9/2009 63

64. Palliative Care
 Gentle sponging and massage can be very soothing.
 This is a time of intimate contact and a good
opportunity to chat to the resident about their
care, fears and worries.
 If skin is very delicate, may want to use a bath oil rather
than soap – this is a good time to monitor skin integrity.
 Change linen and gowns as frequently as needed – the
resident may become clammy as the time of death
approaches.
 Attend mouth care frequently.
Updated 12/9/2009 64

65. Palliative Care
 Mouth Care –
 Poor oral health can result from :
 Medications – opioids, chemotherapy
 Mouth breathing
 Oxygen therapy
 Decreased nutrition, particularly zinc & Vitamin C
 Oral thrush
 A good assessment is vital – treating the cause, and
implementing thorough and regular mouth care is critical to
patient comfort.
Updated 12/9/2009 65

66. Palliative Care
• A soft tooth brush can clean teeth and
mouth without damaging soft mucosa.
• Using mouth swabs and mouth wash
can provide relief to a dry mouth.
• Treat oral thrush with(clotrimazole)
Canesten drops
• Warm salt water mouth rinses can
help ulcers and other breaks.
• Peppermint lip cream for cracked lips.
Updated 12/9/2009 66

67. Palliative Care
 Mobility & Positioning
 As the palliative process progresses, mobility will
decrease.
 The resident will require close monitoring of mobility devices
 As resident becomes bed / chair bound, analgesia may be
required prior to any repositioning.
 Regular skin assessments are required, and use of pressure
relieving devices can be implemented – eg. Spenko
mattresses, sheep skins, spenko booties, air
mattresses, wedges.
 Gentle massage and passive movement of limbs can help
prevent contractures.
Updated 12/9/2009 67

68. Updated 12/9/2009 68

69. Palliative Care
 Shortness of breath (dyspnoea)
 Resident may experience shortness of breath – some
techniques to aid this are :
Updated 12/9/2009 69

70. Palliative Care
 Positioning semi-recumbent or on the side
 Using a fan to blow air around the room.
 Oxygen therapy – only to be used under strict
guidelines – initiating it at this time contravenes
the palliative approach.
 Suctioning – only to be done by RN.
 Increasing morphine +/- hyocine (to inhibit
salivary secretion if very ‘rattly’).
 Gentle physiotherapy.
Updated 12/9/2009 70

71. Palliative Care
 Nutrition & Hydration –
 Food & fluids should be offered throughout the
palliative phase, but never forced.
 Causes of refusal must be explored – eg.
Hypersomnolence from morphine
review by physician; or nausea treat with
anti-emetics.
 Studies indicate that patients being palliated do not
experience hunger or thirst, and remain comfortable
with sips of water or ice chips. (Guidelines for a palliative
approach – p.88)
Updated 12/9/2009 71

72. Palliative Care
 It is considered best practice to encourage food for
comfort and enjoyment, rather than for nutrition’s sake
– ie. Encourage what ever they want to eat, rather than
using protein drinks, etc.
 Enteral feeding may need to be considered if dysphagia
occurs early in the illness.
 PEG or tube feeding is not recommended in later
stages, as the body may not be able to digest this amount
of nutrition when the body’s systems are shutting
down, and there is a greater risk of diarrhoea, vomiting
and aspiration.
Updated 12/9/2009 72

73. Palliative Care
 Elimination –
 Constipation – a thorough assessment is vital – if they are not
eating they will not need to defaecate!
 Is their abdomen distended?
 Are they straining?
 Do they say they need to go?
 Is there unusual nausea – not related to medication?
 Hard stools?
 Treat with laxative program – gentle osmotics, or bulking agents
with suppositories.
Updated 12/9/2009 73

74. Palliative Care
 Elimination –
 Incontinence – may be faecal and / or urinary
 Assess and use continence aids as appropriate.
 If perineal thrush or severe rash is present, the pads can be
removed and the resident nursed on a kylie.
 Prompt & gentle perineal care is critical – use of moisture
barriers, thorough gentle drying (patting) of the area will
minimise trauma and discomfort.
 Stoma & catheter care to be attended as required.
Updated 12/9/2009 74

75. Palliative Care
 Skin care –
 Skin integrity can be altered due to oedema of limbs, cachexia, fragile
skin, sweating, incontinence, chemotherapy or radiotherapy.
 Oedema – elevate the limb, minimal handling, bed cradle, using
‘blueys’ if the limb is weeping.
 Prompt wound management
 Use of medical sheep skins, pressure
mattresses, spenkos, wedges, etc.
 Gentle sponging, avoiding soaps – use bath oils or lotions.
 Soft cotton gowns that wont increase sweating.
 Prompt management of incontinence.
 Ensure diet & fluids are adequate depending on stage of illness.
Updated 12/9/2009 75

76. Updated 12/9/2009 76

77. Palliative Care
 Spiritual needs –
 If advance care planning has been done well, the spiritual needs of
the resident should be clearly known.
 Cultural and religious preferences must be respected and acted
upon.
 Family involvement at this time is critical for access to family priests
or specific cultural practices.
 Pastoral care workers can help comfort staff and residents.
 Complementary therapies can be important to the resident and
family.
Updated 12/9/2009 77

78. Updated 12/9/2009 78

79. Palliative Care
 The room –
 Should be preferably a single room.
 Should be well lit, and well ventilated
 Remove any unnecessary clutter or furniture.
 Encourage mementos, picture, flowers, or other items of comfort to
be within sight.
 May require a fold out bed, or a recliner chair for a relative to sleep
over.
 May have aromatherapy or candles – under strict guidelines.
 Have the resident’s favorite music on a CD player.
Updated 12/9/2009 79

80. Palliative Care
 The family –
 Good communication between the facility staff and the family is
critical at all times through out the palliative process.
 The care staff might be close to the resident, and also be grieving.
This is the time for the family – you should be comforting them, not
the other way around. Staff should seek counselling if they cannot
cope.
 The family should be allowed to stay or visit when ever they wish.
 The family members may wish to help with personal care – this
needs to be monitored carefully, but encouraged if it is positive for
the resident and family member.
 Professional, religious or spiritual counselling or support can be
very helpful at this time.
Updated 12/9/2009 80

81. Palliative Care
 Signs of imminent death –
 Movement slows, facial muscles relax
 Gastrointestinal function slows – abdominal
distension, incontinence, nausea =/- vomiting may occur.
 Body temperature falls – can feel cool, clammy, looks pale.
 Circulation fails – pulse can be irregular, weak & thready.
 Respiratory system fails – Cheyne-Stokes breathing, or weak and
shallow respirations can occur.
 Often the ‘death rattles’ occur as secretions pool in the pharynx and
bronchi – can be distressing to the family, but not the resident.
 Loss of consciousness.
Updated 12/9/2009 81

82. Updated 12/9/2009 82

83. Palliative Care
 Signs of death –
 No pulse
 No respirations
 No blood pressure
 Pupils fixed and dilated.
 The doctor is called to declare death.
Updated 12/9/2009 83

84. Palliative Care
 Care of the body after death –
 Should have been determined in the Advanced Care
Plan.
 The family / loved ones should be allowed to stay as long
as they want.
 Hygiene care may be necessary if incontinence has
occurred – standard precautions followed.
 Cultural / religious wishes are to be taken into account.
Updated 12/9/2009 84

85. Palliative Care
 Ideally, the body should be re-alligned in bed, and made
to look comfortable and presentable for any family or
friends who may wish to spend time with the resident.
 Place a rolled towel under the jaw if mouth is open.
 Clutter is removed from the room, and fresh flowers
placed if possible.
 The funeral home is contacted when the family is ready.
 Follow the facilities procedures regarding jewellery or
valuable removal.
Updated 12/9/2009 85

86. Palliative Care
 Where to seek help –
 Palliative Care Australia
 Local Palliative Care Associations
 Grief counsellors
 www.health.gov.au
 www.eperc.mcw.edu
 www.pallcare.org.au
 www.pallcare.asn.au
Updated 12/9/2009 86

87. Palliative Care
 References :
 “Guidelines for a Palliative Approach in Residential Aged Care”, Australian
Government Department for Health & Ageing, 2006.
www.health.gov.au/palliativecare
 “Fast Fact & Concept #008 – Morphine & hastened death”, Von Gunten, C.
www.eperc.mcw.edu/fastFact
 “Clinical Practice Guidelines for communicating prognosis and end-of-life issues with
adults in the advanced stages of a life-limiting illness, and their caregivers.”
www.mja.com.au MJA supplement, 18 June 2007, Volume 186, number 12.
 “Long Term Care Assisting – Aged Care &
disability”, Scott, K., Webb, M., Sorrentino, S. & Gorek, B. Elselvier
Australia, Marrickville, NSW, 2204.
 “National Palliative Care Strategy – A National Framework for Palliative Care service
Development”, Publications Production Unit, Commonwealth Department of Health
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 www.pallcare.asn.au
Updated 12/9/2009 87